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Author
Topic: Life in the Donut Hole (Read 10479 times)

Before February was half over, I had already hit the dreaded "donut hole" (coverage gap) with Blue Cross, my part D provider.

During the gap, generics are covered.....so I am thankful for that. But what about the other stuff? I first learned I had slipped into the gap by attempting to fill a Rx for Pancrease MT 10.....and they said "that will be $287.00." After I got up off the floor, I told them to just put it back.

BAO (Birmingham AIDS Outreach) is offering to help with our non-covered meds during the gap, so I will find out tomorrow if they are going to come through for me. More hoops (and placed a higher distance from the ground) to jump through, of course....

The joys of being "in the system".....

Sorry to sound so glum, but it is depressing, as well as frustrating. You folks who have insurance coverage through your employers, HANG ONTO IT with both hands and both feet!

Hopefully tomorrow I can report that I have been able to obtain both my Pancrease and my Flomax at the clinic pharmacy. Wish me luck

Hugs,Alan

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"Remember my sentimental friend that a heart is not judged by how much you love, but by how much you are loved by others." - The Wizard of Oz

Actually, it is a federal issue because it was the feds who first came up with the insane idea to begin with.

In New Mexico, which is a very rural state, there are many areas where Part D plans don't cover the donut hole. So, the state created what it called the Medicare carveout which actually takes the place of Medicare Part D and is managed by the state medical insurance pool.

Works pretty well.

Some states, though, have little or nothing to take up the slack created by those daft fools inside the beltway.

Actually, it is a federal issue because it was the feds who first came up with the insane idea to begin with.

Don't cherry pick my comments, sweetness. I was speaking to using ADAP for the donut hole, not the Med Pt. D program itself. If the state you live in is being cheap then grab your activist placards and organize a march, or you could always move. The feds do not mandate to the states that they can or cannot use Ryan White funds in this manner.

You're not getting what I'm saying -- each state can make the decision to use Ryan White funds as the 2nd payer, for co-pays and the donut hole. That's what Pennsylvania does. I would assume New York does as well.

in 2006, I was still covered by a private plan (State of GA), premiums paid by Ryan White funds through GA Dept of Human Resources.

last year, our Alabama MEDCAP program (pays for part D premiums and copays on ADAP formulary meds) had us sign up for Sierra RX. That plan had no donut hole.They did have a lot of $30 and $60 copays. Premiums were high too, about $130 a month I think.

this year, MEDCAP had us all switch to Blue RX, so this is my first time experiencing the donut hole. Caseworkers have been vague, as to the use of Ryan White funds for assisting during the gap period....but at least BAO is willing to help.

« Last Edit: February 20, 2008, 11:31:08 PM by AlanBama »

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"Remember my sentimental friend that a heart is not judged by how much you love, but by how much you are loved by others." - The Wizard of Oz

I do hope it gets worked out, Alan, and that you can get some assistance with the donut hole ($$).

My Part D nightmare continues. I was required to sign up in Mar' '06, but never was able to get it working. Medco (the PDP) said I was registered but not yet confirmed by Medicare, while Medicare would tell me they had no record of any attempts by Medco to register me in a PDP. In the end, the State of WA Health Insurance Pool agreed to take me back under their old pre-part D plan, as they were also unable to resolve the registration issues with Medco (the PDP) and Medicare.

Last week I got hit with a $423 bill for Part D premiums from 2006 on a plan that I was told I wasn't enrolled in, and that I never was able to get my prescription's through.

Thank god I keep good records.

I had to register for a PDP again as of 01/01/08. Registration seems to have gone smooth this time around, but I've yet to test it by filling a prescription. I have a 4k arthritis injectable in the pipeline now, so we shall see...

I am not a LTS, so forgive the intrusion for the posting - but I see this sad scene played out almost every single time I venture into the CVS these days. In this, the wealthiest country in the world, people are having to walk off and leave seriously needed medications sitting on the counter. It is completely inhumane and speaks volumes about our priorities as a nation. The healthcare situation in this country is an atrocity, and nothing short of a source of shame for us.

Oh, yes - save our citizens from bombs raining from the sky, but if they curl up and die from lack of proper medical attention...well, that's ok.

Today, at the clinic pharmacy, I was able to pick up the two drugs in question, Pancrease and Flomax. So I did the appropriate hoop jumping, I suppose. One slight problem was that I needed the pancrease about two weeks ago, and have been doing without it....

Thanks everyone for the support and info. I'm in this (and have been in this) for the long haul, so let's hope and pray it gets better rather than worse !

hugs,

Alan

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"Remember my sentimental friend that a heart is not judged by how much you love, but by how much you are loved by others." - The Wizard of Oz

they had a contract with "Partners in Care" to provide our HIV meds. When those Rx's were filled, they were counted against our Medicare Part D expenses....now that they counted those expensive drugs (for Jan and Feb) towards my total outlay, they now say they have ended the contract, and ADAP will provide our meds. The meds they provide will NOT be counted towards our total out-of pocket. In other words, they used to cost of the meds to get me INTO the donut hole, but won't use them to get me out.

They are basically shifting the burden onto the ASO's and other social service organizations.

What kind of fool politicians think that people with catastrophic illnness have thousands of dollars lying around to pay for expensive medications during thedonut hole period?

I alternate between being angry, bitter, and frightened. Angry that this kind of shit is happening, while our country seems to focus its AIDS fund raising on Africa. Bitter that I am on disability, and dependent on "the system" to keep me alive. Frightened that it will fail me.

Long term survivor? How long is too long? I am blessed that right now my health is stable, and my counts are good. I also know how quickly that can change.

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"Remember my sentimental friend that a heart is not judged by how much you love, but by how much you are loved by others." - The Wizard of Oz

Alan... you have my sympathy..fighting the system when you are sick and frustrated can be a super pain in the ass. I really don't see how they can simply discount the amount already "charged to the hole" ..the govt agency that tracks this ..the Medicare system?... must have a record of those items charged....otherwise how would anyone know you are in the hole? I can see why they would want to stop the program...most agencies work on the low average system..when they get too many people tapping the system way above average it kills the budget...so they opt out.......think about the WalMarts that sell generics at $4.....at the same time they get all those $100 ones that aren't generic....so the average works out for them....only the largest providers can pull off the low average system......i hope you support group....ASO? can help you....just be persistent..as I am sure you have already discovered it pays off eventually but is a real pain in the mean time.

ever since my late partner passed away my mom has tried to get me to move back to NC. My biggest reason for NOT making that move for these many years is that OH provides me just enough assistance. I have no idea what changing states would do; but I couldn't afford to take a hit, so I stay here in the frozen North and am greatful for the coverage I have.

I'm not certain if it's the Ryan White Fund or ADAP, but some agency pays my spenddown requirement so that I'm automatically issured a medical card each month. (that means no trouble if I need to see the doc today, and I get scripts filled at the local pharmacy) When the new Part D crap kicked in, I went from paying $0 a month to $14 a month (for the first 5 months of the yr) in co-pays. That's fine by me since there's no other way I could afford the $2,750 prescription bill a month!

Heaven only knows what hoops Jim and I will have to jump through to get him medical coverage now after his recent HIV and lymphoma diagnosis. Hopefully, Ohio will be good to him too.

I am DEMANDING some answers from our ADAP representatives. There is no way anyone can justify to me how it is fair that they use the cost of my HIV meds to throw me into the donut hole, but won't use them to pull me out.

In the proud tradition of Rosa Parks, I WILL go to Montgomery and show out if I need to.

Next in my sights: Blue Cross Blue Shield of Alabama

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"Remember my sentimental friend that a heart is not judged by how much you love, but by how much you are loved by others." - The Wizard of Oz

I am DEMANDING some answers from our ADAP representatives. There is no way anyone can justify to me how it is fair that they use the cost of my HIV meds to throw me into the donut hole, but won't use them to pull me out.

In the proud tradition of Rosa Parks, I WILL go to Montgomery and show out if I need to.

Next in my sights: Blue Cross Blue Shield of Alabama

YOU GO GIRL!But you know what it's like going against bureaucratic BS. Just saying...don't get your panties all bunched up as you deal with those blank faces and well-rehearsed responses. God forbid they would lose some of their precious positions during cutbacks so that funding is utilized for those whom it was intented!

Alan, I'm proud of you for what you're about to do. I've contacted people in government before regarding these kinds of things. Some will listen and some will take action. Mucho luck and let us know what happens. Luv,Betty

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I've never killed anyone, but I frequently get satisfaction reading the obituary notices.-Clarence Darrow

I am DEMANDING some answers from our ADAP representatives. There is no way anyone can justify to me how it is fair that they use the cost of my HIV meds to throw me into the donut hole, but won't use them to pull me out.

In the proud tradition of Rosa Parks, I WILL go to Montgomery and show out if I need to.

Alan... the one thing the bureaucracy cannot deal with is to have their rules read back to them when they are clearly wrong..... when you "confront" them be ready with a good reasoned presentation about how the original charges counted and now somehow don't count....if you are lucky a "rational" person will hear you and look into the situation ...be sure to leave with names ..phone numbers...and "quotes" from persons .....so you can follow up the next day....Good luck